Surgical Approaches to the Orbit
E. Jason Sabet-Peyman, MD
DISEASE DESCRIPTION
The orbit is a conical unit consisting of the subperiosteal, intraconal, and extraconal spaces. There are a variety of orbital conditions that necessitate access to the orbital space. Some common conditions include orbital fractures, abscesses, tumors, and thyroid eye disease. The best orbital approach will be determined by the nature and location of the condition.
MANAGEMENT OPTIONS
The surgical approach is chosen depending on the location and type of pathology being treated. A guiding principle is to attempt to directly access the pathology while minimizing the amount of critical anatomy that is traversed (Figure 31.1).
Subperiosteal — access to the potential space between the orbital bone and the periosteum
This can be performed through an anterior, lateral, or transcaruncular medial approach.
FIGURE 31.1. Illustration of orbital compartments.
Either a transconjunctival or transcutaneous incision can be used if attempting to access the inferior subperiosteal space; however, a transconjunctival incision is preferred, if possible, because this avoids a cutaneous scar and minimizes the risk of postoperative eyelid malposition. A transconjunctival incision along with inferior cantholysis will give wider access to the orbital floor.
Extraconal — access to the space between the fascial septa that interconnect the extraocular muscles and the periorbita
This space can be accessed through a transcutaneous transseptal approach for the anterior orbit, through a lateral orbitotomy for deeper and lateral pathology, and a medial approach for medial pathology.
Intraconal — access to the space within the fascial septa that interconnect the extraocular muscles or within the muscle cone from the annulus of Zinn to the posterior Tenon’s capsule. This area can be accessed either through an anterior, lateral, or medial orbitotomy approach.
Access to the intraconal space may be facilitated by temporarily disinserting a rectus muscle to improve exposure.
Deep orbit — access to posterior third of the orbit.
Superior transcranial orbitotomy is necessary for lesions in the orbital apex, optic canal, chiasm, or for lesions that extend into the cranium.
Collaboration with a neurosurgeon is indicated in these cases.
INDICATIONS FOR SURGERY
Subperiosteal approaches are used for repairing orbital wall fractures, drainage of subperiosteal abscesses or hematomas, and orbital decompression surgery for thyroid eye disease.
Extraconal approaches are used to access orbital processes lying outside the muscle cone.
Intraconal approaches are used to access intraconal tumors and the optic nerve or nerve sheath, or other intraconal pathology.
Between the intraconal and extraconal spaces are the extraocular muscles. The muscles could be involved in cases of myositis or metastatic tumors. They can be accessed through either an anterior or lateral orbitotomy approach.
Lesions involving the orbital apex or extending intracranially into the cavernous sinus may require a superior transcranial approach in collaboration with a neurosurgeon.
SURGICAL DESCRIPTION
Numerous incisions have been described for the approach to each orbital space (Figure 31.2). Several of the most commonly employed approaches are described here, including the upper eyelid transcutaneous approach for anterior orbitotomy, the lower eyelid transconjunctival approach for anterior orbitotomy, the transcaruncular approach for medial orbitotomy, and the eyelid crease incision for lateral orbitotomy.
 FIGURE 31.2. Common incisions used to access the orbit. |
Upper Eyelid Crease Transcutaneous Anterior Orbitotomy
This approach uses an eyelid crease incision and can be used to access the subperiosteal or extraconal spaces (Figure 31.3).
Mark a skin incision at the upper eyelid crease.
Incise the marked incision site using a #15 blade. Use Westcott scissors or monopolar cautery to sharply dissect through orbicularis to enter the postorbicularis plane.
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